No Ho Residential Care, Inc.

Limitations - Capacity and Ambulatory Status-Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement was not met as evidenced by: Resident #1 was observed housed in the front bedroom previously identified on the facility sketch as the office and now identified as Bedroom #4.

Based on observation the licensee did not comply with the section cited above as the blue trash can was missing a lid and the green trash can was cracked and missing half of the lid] which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above as the water tested in front bathroom read 138.9 degrees Fahrenheit, the back bathroom read 135. 2 degrees Fahrenheit and the Kitchen water temperature read 137.4 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above as the fire rated door installed to separate the 3 back bedrooms and held open by a magnate connected to the hardwired smoke detectors did not activate the magnate to release the door to secure the area and did not close tightly which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the drawer in the front bathroom was observed to be broken, the wall by the toilet had holes that needs to be patched up and the outside areas need general maintainance so that stored items along the home is discarded or stored away which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as there were no grab bars mounted in the shower located in the front bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the facility, Bedroom #1 and Bedroom #3 are missing closet doors which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above per review of all Resident's files,consent forms were not completed, Identification and Emergency Forms(LIC9020) were not completed, a couple of Appraisal/Needs and services were not completed, missing Centrally Stored Medication Destruction Records, .which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the facility, the auditory devices mounted on all three exit doors located in the front, the back door and in bedroom #2 were all tested and were not operational. The batteries were all depleted poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above per review of Staff #2 and Staff #3's files, there weren't any completed LIC308 designating the 2 staff as responsible staff during the day and night shift which poses/posed a potential health, safety or personal rights risk to persons in care.

87506 Resident Records: Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by: Files for Resident #1 - Resident #6 were missing information noted on the LIC809 report and this is a potential risk to the personal rights and a health risk to the residents in care.

Based on observation the licensee did not comply with the section cited above in 1 out of 6 which poses a potential personal rights risk to persons in care.

Based on test of the water, the licensee did not comply with the section cited above in 2 out of 2 tests which poses an immediate health, safety or personal rights risk to persons in care. Water temperature tested 140.6 degrees in the front bathroom and 137.4 degrees in the back bathroom

Based on observation, the licensee did not comply with the section cited above in 1 count out of 1 count which posesa potential health, safety risk to the residents in care

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services.This requirement is not met as evidenced by: Based on interviews and documents reviewed, the Licensee did not comply with the section cited above, as the Licensee failed to ensure that staff are able to communicate effectively with the residents while in care, which poses a potential health and safety risk to residents in care.

87555(b)(8) General Food Service Requirements(b)The following food service requirements shall apply:(8)All food shall be of good quality.. Food in damaged containers shall not be accepted, used or retained.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as expired food was observed in one (1) out of two (2) facility kitchen refrigerators, which poses a potential health, and safety risk to persons in care.

87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement,...(g) Admission agreements shall specify the following:(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license.This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above, as three (3) out of five (5) residents files were incomplete, which poses a potential personal rights risk to residents in care.

87705(f)(1) Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited, as culinary knives and additional sharp items were accessible during physical plant tour to residents with Dementia, which poses an immediate health and safety risk to residents in care.

87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as... cleaning supplies ...This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above, as ointments, and multiple medications were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on LPAs observations, the Licensee did not comply with the section cited above, as the Licensee failed to ensure Facility personnel is competent to provide the services necessary to meet resident needs, as the front door had the facility key in the doorknob and a resident had to open the door for the LPAs due to staff being occupied with another resident, which poses a potential health and safety risk to residents in care.

87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as two (2) out of five (5) resident files did not contain the resident Hospice care plan, which poses a potential health, and safety risk to persons in care.

87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the Licensee did not comply with the section cited above, as the Licensee failed to ensure that staff are able to communicate effectively with the residents while in care, which poses a potential health and safety risk to residents in care.

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance…This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as two individuals (S1, S2) have been working at the facility without a background clearance, which poses an immediate safety risk to residents in care.

87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.This requirement is not met as evidenced by Based on observation, the licensee did not comply with the section cited above as one resident (R1) out of six residents does not have a facility file which poses potential health and safety risk to residents in care.

87203 Fire SafetyAll facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above as the entrance gate was locked from the inside of the property to the facility grounds which poses an immediate safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 is a two person assist and only one staff was at the facility when the LPAs arrived which poses an immediate health and safety risk to R1 in care.